Doctor Q&A

Skin pH with Cheryl Lee Eberting, M.D.– Eczema and Skin pH

Skin pH interview with skin barrier expert, Cheryl Lee Eberting, M.D.of
Skin pH interview with skin barrier expert, Cheryl Lee Eberting, M.D.of

This is the 5th and last post of Skin pH series: Read the 1st post on Understanding Skin pH and its Impact here, 2nd post on Overly Acidic and Alkaline Skin here, 3rd post on Diet, Environment on Skin here and 4th post on Moisturizing and Skincare Products’ impact on Skin and Skin pH here.

We are privileged to have Board Certified Dermatologist Cheryl Lee Eberting, M.D. again for this 5-week skin pH series. Read more on Dr Cheryl Lee here. Dr. Eberting invented the TrueLipids skin barrier optimization and repair technology; a technology that helps the skin to repair itself by recreating its own natural environment.  

MarcieMom: Thank you Dr Cheryl Lee for being with us for the past 4 weeks and today, we focus on eczema skin – a topic which parents/readers of this blog would most certainly be keen to find out!

Eczema and Skin pH

MarcieMom: I read that alkaline pH is associated with skin dryness. Since eczema is characterized by skin dryness, does this mean all eczema skin is too alkaline? Came across a study that even the uninvolved skin of eczema adults have higher alkaline pH than those without eczema. It was stated as 6.13±0.52 on the eczema lesions, 5.80±0.41 on perilesional skin and 5.54±0.49 on uninvolved skin. In the control group, the mean pH of the skin surface was 5.24±0.40.

Dr Cheryl: Yes.  If you have dry skin, eczema, a rash, or an infection on your skin, then the pH is too high.  In atopic dermatitis, there are 7 major problems that lead to the abnormal skin barrier and they are all interrelated with each other.  The problems are as follows:

  1. Skin lipid deficiencies (phytosphingosine, phytosphingosine-containing ceramides like Ceramide 3, cholesterol esters, and very long chain fatty acids have been shown to be particularly deficient in atopic skin, dry skin and aged skin).
  2. Excessive loss of water due to skin lipid deficiencies. (white petrolatum in the gold standard water loss inhibitor.  Paraffin is likely even more effective than petrolatum however.  Certain lipids have also been shown to be very good at inhibiting water loss.  The lipid isostearyl isostearate is one of the most effective lipids as preventing water loss from the skin.
  3. Abnormal pH (partly caused by the lipid deficiencies above, but also then CAUSES a lipid deficiency because the enzymes that make epidermal lipids only work within the optimal skin pH range)
  4. Susceptibility to infection (caused by the lipid deficiencies—some of these lipids are anti-staphylococcal—and caused by the overly alkaline pH).
  5. Inflammation (cause by lipid deficiencies that cause desiccation and entrance of allergens and infection into the lower levels of the epidermis which then leads to infection.)
  6. Allergy (atopic skin is susceptible to allergic contact dermatitis to certain chemicals at higher rates than non-atopic skin.  This is also a result of all of the above problems.)
  7. Abnormal calcium gradients.  (The epidermis has calcium gradients that lead to lipid production and to normal cell cycling.  In atopic dermatitis, these gradients are disrupted and contribute to lower levels of lipid production and dysfunctional cell cycling.)

These 7 problems are present in the entire skin barrier of an atopic and this is why is it so very important to focus on skin barrier optimization that addresses all 7 of these problems simultaneously.

MarcieMom: What skincare measures (if any) should parents of eczema children take to help the child’s skin to reduce its alkalinity?

Eczema and Skin pH - Steps to take

Dr Cheryl Lee:

1. Bleach Baths Really Work:

As I discussed in this post, I think bleach baths work as part of the eczema skin care regimen, but they also alkalinize the skin a little bit too.  The target concentration of a bleach bath is .005% hypochlorite ion.  Because there are different sizes of bathtubs around the world, it is difficult to just tell you how much bleach to put it.  In the United States, we have a standard-sized tub that most people have in their homes. (And we have ridiculously large tubs too).  For the regular-sized American tub, I recommend 1/8 cup if the tub is 1/4 full, or 1/4 cup is the tub is 1/2 full or 3/8cup is the tup is 3/4 full.  For very mild cases of eczema, bleach baths may not be needed, but if there is any crusting or scabbing, try taking the bath three times a week.  The more severe it is, the more frequently you should take a bleach bath.

Special Trick for Babies with eczema:  If your child will not stay in the bathtub long enough to have an effective bleach bath (about 20 minutes), then try using a large tupperware/plastic container INSIDE your shower for your child to play in.  I recently discovered this on my own children and now I can’t get them to STOP taking a bath (which is bad for eczema too;  too many baths can dry out the skin and make it worse).

Of note, we have always thought that the bleach bath is working because it is killing the Staph. aureus on the skin.  Well, recent studies showed that it is not only the killing of the Staph, but it is also due to the low level oxidation exposure.  When the skin is exposed to very low levels of oxidation, the skin then turns on anti-inflammatory and reparative pathways.  This is totally counter-intuitive, but is very, very interesting and makes me thing that our creator really knew what he was doing!

2. pH-Adjustment After Bathing and After Bleach Baths OR If you Don’t Have Access to Bleach:

After taking a bleach bath, use a pH-protecting gel with vinegar in it or use a vinegar spray diluted with one part vinegar and six parts water to all affected areas.  (white vinegar or apple cider is best—no rice or balsamic vinegar).  This should then be covered with a pH-optimized moisturizer (pH 4.6 to 5.6….a little more acidic may be beneficial, but more alkaline is bad).

Of note, I had a patient come to see me all the way from Cambodia.  When she went home to Cambodia, she was unable to find bleach anywhere.  If this is the case, I have seen similar benefits from vinegar baths (it takes A LOT of vinegar–around 6 cups to a half-full regular American-sized tub).  Or, you can do the vinegar spray or pH-protecting vinegar gel if you cannot take a bath.

3. Moisturize the Skin Barrier AT LEAST Two Times a Day With Skin Barrier Optimizing Moisturizers, But Four Times Works Better and Faster:

I think it is very important to moisturize atopic skin at least twice a day WHEN IT IS NORMAL LOOKING.  When it is broken out AT ALL, I always advise that my patients use their eczema products (we use the TrueLipids Eczema Experts 1% Hydrocortisone Cream followed by the TrueLipids Relieve & Protect Ointment) up to four times a day UNTIL the skin is normal looking.  Once the skin LOOKS and FEELS normal, then my patients switch to the TrueLipids Ceramide+ Cream followed by the ointment twice a day for maintenance.  It is very important to treat ALL affected areas and not just the areas that are scabby looking.  What I mean by this is that even the areas of the body like the stomach and back that may look a lot better that the worst areas on the arms and legs, must also be treated until they ARE normal; normal looking and normal feeling.

The skin on the trunk often has what we call folliculocentric atopic dermatitis where each little hair follicle is more accentuated and is a little bit lighter in color than the skin around it.  This is active disease and needs to be treated just as much as the scabby, inflamed areas do.  The skin on the trunk usually heals much more quickly than does the skin on the arms and legs and, as it heals and goes to normal, the hydrocortisone can be replaced with the Ceramide+ Cream.

4. The Maintenance Moisturization Phase is Just as important as Treatment Phase:

I cannot stress the importance of maintenance moisturization.  Plan on at least twice daily moisturization for the rest of your life.  You must avoid all common allergens in your skin care products too.  There are certain allergenic chemicals that are known to be more common in people who have atopic dermatitis and you should at the very least avoid them.  I will write more about this in a later post.  By optimizing the skin barrier, you can prevent it from breaking down into eczema and can probably also control other allergic diseases like asthma and hay fever too.

5. Wet Wrap Therapy if Your Eczema is Severe:

If your eczema is very, very severe, you will need to do wet wrap therapy where you take your bleach bath, then do your pH adjustment and then wrap the skin in WHITE COTTON (not wrinkle-free type fabric because is often has formaldehyde in it) pajamas or bandages every day.  I have even had a few patients who have needed to do wet wraps during the day too.  Don’t use ACE wraps or anything that has latex or spandex in it as this can be allergenic for atopic skin too.  Once the wraps or pajamas are on, spray them down with water and cover with a layer of dry clothing and go to bed.

6. Break Through Low Dose Steroid Maintenance in Severe Cases:

For more severe cases, once the skin is completely back to normal, I recommend using the TrueLipids 1% hydrocortisone cream twice as part of your maintenance routine.  Studies have shown that low levels of hydrocortisone like this can keep one in remission and prolong time between relapse. Studies have also shown this benefit from treatment a few times a week with Elidel or Protopic, but I do not prefer them as I don’t find them to be very effective, they are very expensive and they are not the safest drugs in the world. (That being said, if you are allergic to glucocorticoids, then Elidel and Protopic can be a lifesaver.)

Also very important is that of glucocorticoid allergy.  Studies have shown that between 24 and 90% of children with atopic dermatitis who are patch tested are allergic to at least one glucocorticoid.  If your child is one who seems to either not get better with hydrocortisone or who gets a little better but then seems to get worse, he/she may be allergic to it.  It is always a good idea in this case to get your child patch tested to see what they are allergic too and to learn what classes of gluccocorticoids that your child can use.

7. Allergen Avoidance and Patch Testing if Needed:

I cannot stress enough how important it is so avoid allergens in your skin care products, soaps, detergents AND in the products that family members are using.  Find a dermatologist who is experienced in patch testing (not prick testing) for allergic contact dermatitis (ACD).  ACD is an allergy to a chemical that is coming in contact with the skin.  For example, fragrance allergy is one of the most common allergens in atopic dermatitis.  If daddy is wearing cologne and baby touches his shirt, this can equal a month of eczema flare for baby.

The whole family needs to avoid the allergen triggers.  In addition to fragrance (which cross reacts with essential oils and many plant extracts), common allergens in atopic dermatitis include nickel, formaldehyde releasing preservatives, propolis (in beeswax), neomycin, bacitracin and more.

Thank you Dr Cheryl Lee for going through with us the factors that affect skin pH with practical steps on what parents can do. It will definitely help parents to be committed to these measures with the right understanding of why to take them. Thank you once again!

Doctor Q&A Eczema Tips

Skin pH with Cheryl Lee Eberting, M.D.– Moisturizer and Skincare Products

Skin pH interview with skin barrier expert, Cheryl Lee Eberting, M.D.of
Skin pH interview with skin barrier expert, Cheryl Lee Eberting, M.D.of

This is the 4th post of Skin pH series: Read the 1st post on Understanding Skin pH and its Impact here, 2nd post on Overly Acidic and Alkaline Skin here and 3rd post on Diet, Environment on Skin here.

We are privileged to have Board Certified Dermatologist Cheryl Lee Eberting, M.D. again for this 5-week skin pH series. Read more on Dr Cheryl Lee here. Dr. Eberting invented the TrueLipids skin barrier optimization and repair technology; a technology that helps the skin to repair itself by recreating its own natural environment.  

MarcieMom: Thank you Dr Cheryl Lee for helping us understand skin pH and sharing with us last week on what to watch out for in our diet and environment. Today we focus on the skin’s itself and the products we use on it!

Endogenous Factors and Skin pH

I understand that newborn baby’s skin is of higher pH of about 7. Moreover, certain parts of the body is more acidic/alkaline than others.

MarcieMom: What are the key endogenous factors parents should note to help manage the child’s skin pH? For instance, not let sweat stay on skin? What about ethnic and genetics?

Moisturizer and Skincare Skin pH)

Dr Cheryl: Babies are born with a relatively alkaline skin pH because they’ve been incubating inside the mother’s more alkaline amniotic fluid.  Newborn skin is covered with an amazing moisturizer called vernix caseosa; a waxy coating that obviously works to make the babies relatively waterproof while in the womb.  Within days of birth, the pH of the newborn skin begins to dry out, acidifies and then the acid mantle becomes intact.  For this reason, it is important to use moisturizers that are in the optimal pH range for babies too.  In a recent preventative study of the infant siblings or children of those who have atopic dermatitis, twice daily moisturization with a hypoallergenic (meaning no fragrances, no essential oils, no plant extracts, no formaldehyde-releasing preservatives, no lanolin, no neomycin, no bacitracin, no methylchloroisothiazolinone) moisturizer in these newborn babies lead to an approximately 50% reduction in rates of new onset atopic dermatitis.   I love this study because it tells us a lot about the connection between our skin barrier and our immune system.  By optimizing your skin barrier and sealing it off from the outside world, and by avoiding as many chemical exposures as possible, we can prevent the immune system from developing the inflammation associated with eczema!

I would also venture to say that this may be the way to avoid asthma as wellWhen allergens come in contact with the skin, then the allergic type of inflammation is turned on.  On the other hand, it has been shown that if you can avoid letting allergens (including foods!) from coming in contact with the skin long enough, then your child’s immune system will build up tolerance to the food when it is presented to the immune system of the gut. What this tells us is that, in susceptible populations, the skin barrier needs a little help as it is maturing. By using a pH-optimized and hypoallergenic moisturizer twice a day, you may be able to help your baby to build an effective skin barrier that is not as overreactive as it is in eczema.  Our skin is truly the window to our immune system and skin barrier optimization (SBO) is extremely important in treating and preventing atopic dermatitis.

As for ethnic variability in the skin barrier, there have been documented differences in relative concentrations of lipids in the skin of caucasian versus asian versus black skin thought the relative ratios are all the same.  To my knowledge, there is no interethnic difference in the optimal skin pH.

Genetics absolutely play a role in the propensity to develop atopic dermatitis.  Conditions like ichthyosis vulgarism predispose one to dry skin, an overly alkaline skin pH and to the development of atopic dermatitis.

As for sweat, the biggest problem is the irritancy of the sweat itself.  The salts from sweat can crystalize and act as an irritant to the skin.  If you can see that your baby’s sweat has dried and has a salty residue, then I would recommend rinsing it off with plain water (no soap) to prevent it from becoming an irritant.  If the sweat is not crystalized, I wouldn’t worry about it much.

Food on the skin; again this is another issue of major importance in atopic dermatitis.  Studies have shown that when food is left on the skin for extended periods of time in early infancy, the child is more likely to develop an allergy to that food.  Be sure to wash your child’s hands and face after eating!

Products and Skin pH

Marcie Mom: Many products are marketed as of ‘skin’s natural pH’ or ‘pH-balanced’. What does this mean? When can a parent start moisturizing baby’s skin (given the pH changes)?

Dr Cheryl: The term “pH-balanced” is completely unregulated and could mean anything—including that the product could actually be alkaline.  The consumer has no way to knowing what the pH of a product is unless they actually test is with a pH meter or if the manufacturer were to put the pH ON the package.  As for the TrueLipids products, we conducted long term stability studies on the pH of our formulations so we know that they are within the optimal range of 4.6 to 5.6 for extended periods of time and even in high-heat environments.  Additionally, many products contain benzoic, lactic, sorbic or citric acids to bring the pH down to the acidic levels.  These acids can sometimes be allergens (sorbic acid and benzoic acid can cause hives when they come in contact with the skin.  Benzoic acid can cross react with those who have fragrance or balsam of Peru allergies which are common in atopic dermatitis) or these acids can act as an irritant if they are formulated in such a way that the acid can precipitate and turn into a salt easily.  The pH system in the TrueLipids products employs and acid called gluconolactone.  I chose this poyhydroxy acid in my formulations because it is not only an effective way to acidify a formulation without crystallization of the acid (in my own experimentation), but it has also been shown to reduce the loss of water from the skin and has anti-oxidant and DNA-repairative properties as well.

As for the appropriate time to start moisturizing the skin of a newborn, the skin of the newborn acidifies within the first few days of life.  Three weeks of age has been shown by Simpson et. al., to be a safe and effective time to start moisturizing the skin of a newborn who is at high risk of developing atopic dermatitis.  In this study, the babies were moisturized at least once a day and 50% fewer cases of atopic dermatitis were noted by the age of six months!  The skin of a newborn acidifies within the first few days of life and so I do not think it is necessary nor beneficial to use a more alkaline moisturizer on a newborn.  It is probably best to leave the skin of brand new babies alone until they are three weeks old.  Of note, studies have shown olive oil to be detrimental to the newborn skin barrier, so it is best avoided.

MarcieMom: Which products are clearly bad for skin due to its pH level? For instance, detergent and soaps? These anti-bacterial products (containing benzoyl peroxide, triclosan, sodium lauryl sulphate and sodium laureth sulphate) help to kill staph bacteria but its pH level (and ingredients) lead to skin irritation. What is the skincare approach to ensure killing staph bacteria adequately without causing skin dryness?

Dr Cheryl: First of all, it is best to limit the use of soaps altogether when possible.  Soap should only be used when needed to remove dirt or oils that don’t belong on the skin.  Otherwise, soaps should be revered for washing of hands and hair when it is dirty.

Soaps, cleansers, shampoos and body washes should all be in the optimal acidic range of 4.6 to 5.6 and should be non-alkaline.  Products that deposit and oil as you use them can also be beneficial.

Avoid any surfactants with the word “sulfate” at the end.  Sulfates have been demonstrated to be very destructive to the skin barrier and remove the lipids from the skin barrier leading it to dry out and to develop allergies to chemicals more easily.

As for optimal soap surfactants, there is a lot of very interesting science that can direct us to make the best choices for our sensitive skin.  Surfactants are designed to remove dirt and oils from the skin, but the problem is that they can also remove the lipids from the skin as well.  This leads to disruption in the skin barrier and exacerbates all the skin barrier problems in atopic dermatitis.

The best Soap to use for atopic dermatitis:

It has been postulated that charged anionic surfactants may be more detrimental to the skin barrier than nonionic surfactants, but it has been noted that nonionic surfactants more efficiently remove stearic acid (a fatty acid in the epidermis) than to anionic surfactants.  Anionic surfactant-based cleansers also alter the lipids of the epidermis more than do the anionic surfactant sodium cocoyl isethionate.  Another factoid about surfactants is that the larger the polar head group on the surfactant, then the less it is able to interact with and remove lipids from the skin barrier.

Of note, a recent study by Belsito et. al., showed that the surfactant cocamidopropyl betaine (CAPB) is more likely to cause allergic contact dermatitis in people with atopic dermatitis than in those who do not have atopic dermatitis.  

I also like to avoid the glucoside surfactants as they are also relatively common allergens in the general population and can cause eczema of the eyelids and hands that can be very tricky to figure out.  I have been working on a cleanser that is optimized for atopic skin and it will be available next spring.  It will have the best surfactants for sensitive skin.

One more little note in regards to cleansing atopic skin; never use anything to scrub the skin other than your hands or a very gentle wash cloth.  Loofah sponges, and scrubbing brushes do not belong on atopic skin (or normal skin for that matter).

Thank you Dr Cheryl for sharing what to look out for in cleaning and moisturizing our eczema child’s skin. Next week, we will focus on Eczema and Skin pH, and how to reduce the alkalinity of eczema skin.

Doctor Q&A

Skin pH with Cheryl Lee Eberting, M.D.– Diet, Environment on Skin

Skin pH interview with skin barrier expert, Cheryl Lee Eberting, M.D.of
Skin pH interview with skin barrier expert, Cheryl Lee Eberting, M.D.of

This is the 3rd post of Skin pH series: Read the 1st post on Understanding Skin pH and its Impact here and 2nd post on Overly Acidic and Alkaline Skin here.

We are privileged to have Board Certified Dermatologist Cheryl Lee Eberting, M.D. again for this 5-week skin pH series. Read more on Dr Cheryl Lee here. Dr. Eberting invented the TrueLipids skin barrier optimization and repair technology; a technology that helps the skin to repair itself by recreating its own natural environment.  

MarcieMom: Thank you Dr Cheryl Lee for helping us understand skin pH – what happens in an ideal skin pH 4.6 to 5.6 environment and what goes wrong when it’s too alkaline or acidic. Today we put these knowledge to use on how we can have the right diet and environment for our skin pH!

Diet and Skin pH

There’s quite a lot of websites proposing that we eat more alkaline foods such as fruits and vegetables of pH 8 to 10 and less acidic foods of pH 3-4 such as soda and sugar drinks.

MarcieMom: How does what we eat affect our skin’s pH? Do you in your practice recommend diet for eczema kids based on food pH level, or should it be based on anti-inflammatory properties, or whether it had been studied to improve eczema (e.g. omega 3)?

Diet Environment on Skin pH

Dr Cheryl Lee: I don’t recommend diets based on the pH of foods, but rather, I recommend diets that are as close to the way they come out of the ground as possible and I certainly do recommend against the ingestion of any processed foods, drinks and candies.  The body has robust pH buffering capacities that can help to keep the body at an optimal pH.  More important are the effects of oxidation in our diets.  I like to explain it this way; our bodies come with a certain amount of “anti-oxidant juice”.  When we eat processed foods, animal proteins and sugars, our anti-oxidant capacious are called upon and utilized.  When we eat too much of these foods, we exceed the body’s ability to replace the anti-oxidant juice and then the body becomes damaged by the free-radicals and excess sugars that are generated when we over eat or when we eat unhealthy foods.

I think the most important dietary approach we should all take is to limit the ingestion of animal proteins as much as possible.  Animal proteins have been demonstrated to increase rates of carbamylation.  Carbamylation is a metabolic phenomena that happens when we ingest animal proteins. The breakdown products of animal proteins as well urea (this is why I also advise against the use of urea on the skin) in a pro-inflammatory environment that promotes high blood pressure, autoimmune disease, diabetes, heart disease, cancer and more.  Interestingly, a recent study even showed that in people who have an infection of the gut with the H. pylori bacteria are unable to adequately detoxify the heterocyclic amines that are generated when meat is cooked.  The H. pylori infection make the gut unable to detoxify these chemicals and these chemicals lead to gastric cancer.

Excess sugar also leads to something called glycation.  Glycation is what happens with excess glucose and glucose metabolic products permanently bind to fat, proteins and even nucleic acids (in our DNA).  The combination of the excess glucose and the proteins and fats are called advanced glycation endproducs (AGEs) and they are what ‘gunk up the system’ and lead to many pro-inflammatory pathways.

I think it is very important to eat lots of fruits, nuts and vegetables and to limit the intake of sugar and animal protein. Vitamins B1, B3, B6, B12, C and others can be helpful in promoting better food metabolism and in limiting the effects of poor diet.

Environment and Skin pH

Smoking, pollution, water and sun also affects the skin pH.

MarcieMom: Dr Cheryl, can you share with us the main environmental contributors and whether it makes our kids’ skin more alkaline or more acidic? What if there are certain factors that can’t be limited, for instance, the water available.

Dr Cheryl: Lets start with water.  The pH of your particular water supply can be quite variable and can be very alkaline.  I think this might be part of the problem in atopic dermatitis and may be part of the puzzle that is missing.  We (dermatologists) are having our patients take dilute bleach baths that are adding (though ever so slightly) to the alkalinity of the water and the skin.  We do know that the benefits of bleach baths are irrefutable and substantial though.  I have started advising the use of a vinegar-based gel to my patients after their baths.  They apply this gel to all areas that are affected by eczema and then apply their moisturizers or other topical medications right on top.This seems to be very helpful. This pH gel is something that I have filed a patent for and will be on the market next spring.

Another option is to use a vinegar spray.  For this I advise that you mix one part white vinegar (not rice vinegar, not balsamic vinegar) from grain (make sure it is not from wheat if you are allergic to wheat) or apple cider vinegar (preferred) with six parts of water and put it in a spray bottle and spray it on the areas of eczema.  Follow this with your regular moisturizers or medication.  I have also had some of my patients use vinegar baths rather than bleach baths and they too have benefited greatly.

I also want to mention the effects of air quality on eczema and our overall health.  Studies have shown that INDOOR air pollution can have a major detrimental effect on our health and leads to increased rates of asthma and related conditions and to the overall burden of disease.  Chemicals like polyaromatic hydrocarbons (from paints, glues, solvents, cleansers) can increase the rates of many health problems.

I always am sure to use VOC free paint in my home.  If I paint my furniture, I will leave it outside or in the garage for several weeks before I bring it inside.  If you can smell it, then you shouldn’t have it in your house.  When I redid the carpet in my home, I researched every little facet of carpet chemistry and found that an all-wool carpet is probably the safest carpet to have for this same reason.  The newer ‘no-stain’ carpets are bathed in a chemicals that is then baked on to make the carpets resistant to staining.  These chemicals have been shown to be very detrimental to our health as well.

A few more things I do in my home to help the air quality is to be sure to vent the air when I cook (smoke from cooked food is particularly pro-inflammatory and carcinogenic).  I avoid the use of cleaning chemicals in my house too.  I usually will use plain old fragrance-free soap and water, or vinegar, or a little bleach (when someone has the stomach flu) and that is it.  I intentionally avoid the use of antibacterial soaps and household cleaners as they are unnecessary, toxic and actually induce bacterial resistance in our homes and our bodies.

In addition to indoor air pollution, outdoor particulate air pollution is even pro-inflammatory and has been documented to contribute to 22% of the global burden of disease that can be attributable to one’s environmental factors.  A study just came out recently that even correlated exposure to polyaromatic hydrocarbons in air pollution to the rates of Attention Deficit & Hyperactivity Disorder (ADHD).  Numerous studies have also correlated ADHD to eczema and I believe there has got to be an environmental correlation to the increased rates of eczema too.  For years we dermatologists have been schooled on “the hygiene hypothesis” of eczema due to lower rates of eczema detected in children who grew up in rural areas as compared to those who grew up in urban settings.  The thought has been that a rural lifestyle exposes one to more bacterial and parasitic antigens earlier in life and that this was to be somewhat protective.  I believe the hygiene hypothesis is actually the complete opposite and that is should be called something more like the “lack of environmental hygiene hypothesis” as the effects of pollution in our food, air, and water is clearly and irrefutably a contributing factor to countless health problems and most likely to eczema as well.  This concept is very well established from a scientific standpoint, but is lacking in public education.  It is my hope that people with come to understand the role of toxins in their environment and that they may take actions to limit them.

Thank you Dr Cheryl for sharing with us what you practice in your home too! Next week we will continue with understanding what products we can use to get our child’s pH right!

Doctor Q&A

Skin pH with Cheryl Lee Eberting, M.D.– Over Acidic or Over Alkaline

Skin pH interview with skin barrier expert, Cheryl Lee Eberting, M.D.of
Skin pH interview with skin barrier expert, Cheryl Lee Eberting, M.D.of

This is the 2nd post of Skin pH series: Read the 1st post on Understanding Skin pH and its Impact here.

We are privileged to have Board Certified Dermatologist Cheryl Lee Eberting, M.D. again for this 5-week skin pH series. Read more on Dr Cheryl Lee here. Dr. Eberting invented the TrueLipids skin barrier optimization and repair technology; a technology that helps the skin to repair itself by recreating its own natural environment.  

MarcieMom: Thank you Dr Cheryl Lee for helping us understand skin pH – we learnt last week from you that skin pH impacts lipid-producing enzymes and skin bacteria. Today, we aim to understand what would happen in an overly acidic or alkaline skin!

MarcieMom: I read that the acid mantle is beneficial to skin due to (i) reduction of moisture evaporation from stratum corneum (upper skin layer) and (ii) discourage bacteria and fungi growth. Conversely, a more alkaline skin pH is prone to dryness and encourages growth of pathogens (from M.symphodialis) that promote skin inflammation. Moreover, skin pH affects Sphingosine production (a skin lipid) that in turn, also impacts skin flora.

This is all quite confusing!

Can you explain if our skin can be over-acidic or over-alkaline? And if yes, how does it impact our skin structure?

When Skin is over Acidic or Alkaline

Dr Cheryl Lee: Our skin can be overly acidic, or it can be in the optimal range of 4.6 to 5.6, or it can be overly alkaline.  When there is any sort of epidermal disruption such as seen in eczema, a rash, an infection, inflammation, or when the skin comes in contact with soap, bleach or even tap water, then the pH of the skin becomes overly alkaline. This is when pH of the skin exceeds the optimal lipid-producing range of 4.6 to 5.6 and the ceramide-producing enzymes slow down or stop producing ceramides.  With decreased skin lipid production, the skin loses water more rapidly and becomes dried out and more itchy….then we start to scratch and bacteria are introduced which then leads to an elevated pH and inflammation.  This leads to an ever more elevated pH and more inflammation and the rash that we call atopic dermatitis.  Again, you can start to understand that the Itch Scratch cycle is more than just itching and scratching.

Ceramides are only one of the lipid species in the epidermis, but are very important in preserving the antimicrobial functions of the skin as well as preventing loss of water from the skin.  Fatty acids are also an important group of lipids that are involved in contributing to the natural acidity of the skin barrier and to the skin’s ability to discourage growth of unfriendly bacteria.

Studies have shown that “hyper acidification” of the skin barrier (down to 3.5ish) with polyhydroxy acids (gluconolactone and lactobionic acids) may actually be beneficial and may hasten skin barrier optimization.   Interestingly, another acid, 18-B glycyrrhetinic acid, can also help to optimize the skin pH, and importantly, it has also been shown to be effective at controlling Malassezia species from overgrowing on the skin. These three acids are the acids that I prefer to use on the skin for these reasons. We do know that hyper acidification with other acids such as citric and lactic acids can be more irritating to the skin barrier due to their propensity to turn into a salt once applied to the skin. If the skin barrier is really excessively acidic (i.e. a pH less than 3.5), it can be physically destructive to skin tissue (a chemical peel) and will break it down. I think it is best to stay as close to 4.6 and 5.6 range, however, it may also be beneficial to be slightly more acidic than this.

Effects of OFF-Balanced pH Skin

MarcieMom: I see on beauty sites quite a few skin conditions being attributed to over-acidic or over-alkaline skin. For instance, alkaline skin is associated with:

  • Dryness—not enough lipids are being produced.
  • Increased sensitivity
  • More prone to sun damage
  • Eczema
  • Acne
  • Wrinkles (sagging skin from deterioration of collagen cells)

Acidic skin is associated with:

  • Skin redness
  • Skin inflammation
  • Painful to touch
  • Pimples

Is the above correct? Moreover, we know that skin conditions are often multi-factorial, so is it over-simplistic to attribute the skin’s pH to a skin condition?  

Dr Cheryl: Overly alkaline skin is indeed associated with dryness, increased sensitivity, being more prone to sun damage, eczema and acne.  Overly acidic skin doesn’t usually happen unless an acid is applied to the skin to change the pH as is the case when we do a chemical peel on the face and indeed, a chemical peel will make your skin more sensitive to the touch, more red, inflamed and painful, but these symptoms are usually short-lived and will resolve once the skin has repaired itself from the chemical peel.

Interestingly, we do know that ceramide production is pH-dependent and we do know that ceramides are involved in controlling matrix metalloproteinase (MMP) production.  The MMPs in the skin are involved in regulating and controlling inflammatory responses after sun exposure and can lead to the breakdown of collagen and elastin.  For this reason, ceramides are important after sun exposure, and the pH is important for ceramide production.  Also very important is the role of the pH in eczema prone skin where there is a disrupted skin barrier which results in a rash, and there is infection/colonization from Staph. aureus.

Thank you Dr Cheryl for being ever so patient in enlightening us about the skin pH. Next week, we will focus more on our diet and skin pH, something practical that parents can work on for their eczema kids.

Doctor Q&A

Skin pH with Cheryl Lee Eberting, M.D.– Skin pH and Eczema Impact

Parents are always looking at getting the right product for their children with eczema – many of these are marketed as pH-balanced and it can be confusing whether alkaline, acidic or neutral is good.

We are privileged to have Cheryl Lee Eberting, M.D. to help answer our questions in this 5-week skin pH series. Cheryl Lee Eberting, M.D. is a Board Certified Dermatologist and a past clinical research fellow of the National Institutes of Health. Dr. Eberting invented the TrueLipids skin barrier optimization and repair technology; a technology that helps the skin to repair itself by recreating its own natural environment.

Skin pH and Eczema with Dr Cheryl Lee Eberting
What is our Skin pH?

pH stands for the potential of hydrogen, which is a measurement of the hydrogen ion concentration. pH scale ranges from 1 (most acidic) to 14 (most alkaline) with 7 representing neutral. The skin pH comes from the ‘acid mantle’, which is an emulsion of secretions from sebaceous (oil) and sweat glands and decomposed corneocytes (upper skin layer cells).

MarcieMom: Dr Cheryl Lee, this acid mantle on the surface of the skin is what gives the skin its pH level. However, the optimal pH of the skin barrier seems to change with more studies being conducted. I understand that the ideal pH of the skin barrier is thought to be 5.5, but it is now accepted as being more acidic from 4.5 to 5.0.

Skin pH eczema

Dr Cheryl Lee: You are right about the great variation in the ideal skin pH in the medical literature.  When you read the skin pH literature, there seems to be a range of between 4.6 to 5.6 depending on the study and where on the body the pH was tested. Dermatologists do agree that the skin should have an acidic pH somewhere in this range.  When our skin comes in contact with alkaline substances such as soap or even tap water, the optimal pH is exceeded.  Tap water has been shown to alkalinize the pH of the skin for six hours. This means that the natural buffering systems in the skin barrier take up to six hours to buffer the skin barrier back into the optimal acidic range when the skin comes in contact with tap water. Soap and bleach are even more alkaline than tap water and obviously have an even more dramatic effect on alkalinizing the skin barrier.

Why is More Acidic Skin pH the ‘Ideal’?

Dr Cheryl Lee: The epidermis is composed of the epidermal lipid barrier which contains many lipids (fats) that serve to keep the skin water proof, infection-proof, chemical and allergen proof and much more.  These epidermal lipids are composed of four main classes including Ceramides (47%), cholesterol (24%), fatty acids (11%), and cholesterol esters (18%).  The ceramide fraction is a very important part of the lipid bi-layer that lines the corneocytes in the epidermis.  We know that ceramides are important for preventing water loss, infection, irritation and in helping to regulate the pH as well.  The main enzymes that make ceramides are called B-Glucocerebrosidase and acid sphingomyelinase.  Both of these enzymes have an optimal pH in which they can do their work and produce ceramides. If the pH of the skin exceeds about 5.7, then there are other enzymes(serine proteases) that become activated in the skin and will literally chop up and metabolize the ceramide-producing enzymes rendering the skin unable to make skin barrier lipids and to repair itself. As the skin barrier lipids can no longer be replenished, then the skin barrier begins to break down. Thus, we learn how ceramide production can come to a halt and affect the integrity of the skin barrier when the pH of the skin is too alkaline.

Ceramides are important for preventing water loss, infection, irritation and in helping to regulate the pH as well.

Optimal Skin pH and Good/Bad Bacteria Skin Colonization

Another important facet of the optimal pH of the skin is the role it plays in the skin’s microbiome. The term microbiome describes all of the good and bad bacteria that live on our skin.  An acidic pH discourages the growth of bad bacteria and encourages the growth of good bacteria.  Staph. aureus for example, prefers a more alkaline environment and does not like to grow in the normally acidic environment of the healthy skin barrier.  Good bacteria like Staph. epidermis prefer the acidic environment and do not thrive in an alkaline environment.  As you may know, people who have atopic dermatitis are particularly susceptible to the overgrowth of Staph. aureus.  This has a lot to do with the overly alkaline environment of the skin barrier AS WELL AS the particular lipid deficiencies that are present in atopic dermatitis.

Acidic pH discourages bad skin bacteria growth

Skin Barrier Lipids are Naturally Anti-Staphylococal

The skin barrier in atopic dermatitis has been shown to have particular lipid deficiencies. For example, there are well-documented deficiencies in phystosphingosine, phystosphingosine-containing ceramides like Ceramide 3, in cholesterol esters (NOT CHOLESTEROL) and in Very Long Chain Fatty Acids. Phytosphingosine for example, has been shown to have anti-staphylococcal and anti-candidal effects and has been shown to be deficient in aged, dry and eczema-prone skin. Phytosphingosine deficiency leads to the phytosphingosine-containing ceramide deficiency. These ceramides are produced by the pH dependent enzymes and are not produced at appropriate levels in atopic skin.  This contributes to the colonization/infection by Staph. aureus and becomes part of the wicked cycle that we all know in atopic dermatitis.  You can see, this is a very interconnected cycle of lipid deficiency, alkaline pH, infection….repeat.  We can attempt to break the cycle by addressing all of these things simultaneously.

Thank you Dr Cheryl Lee in explaining the importance of skin pH; next week, we will learn more about what happens in off-optimal pH skin.